Inform that this can cause sexual dysfunction 15. The olols o Implementation o Advise client to utilize other means to control blood pressure such as diet modification, exercise, lifestyle changes, etc o Advise to eat high fiber foods to counter-act constipation 16. The Prils o The Angiotensin Converting Enzyme Inhibitors o These are commonly called ACE inhibitors because the agents BLOCK the conversion of AI to AII in the LUNGS. o These agents alter one of the mechanisms of blood pressure control- the RAAS or renin-angiotensin-aldosterone system. o Angiotensin II is a very powerful vasoconstrictor and stimulus for the release of aldosterone. 17. The Prils o The Angiotensin Converting Enzyme Inhibitors o Pril o Benazepril o Captopril- prototype o Enalapril o Enalaprilat o Fosinopril o Lisinopril o Moexipril o Quinapril o Ramipril o Trandorapril 18. The Prils o Pharmacodynamics: The mechanism of action of the ACE inhibitors o These agents prevent the conversion of angiotensin I to angiotensin II by inhibiting the enzyme in the lungs- the angiotensin converting enzyme. o The action leads to decreased AII and decreased aldosterone level leading to a decrease in blood pressure. 19. The Prils o Pharmacodynamics: The mechanism of action of the ACE inhibitors o The effect of lowering the blood pressure is attributed to the decrease in cardiac workload and decrease peripheral resistance and blood volume . 20. The Prils o Clinical indications of the ACE inhibitors o Hypertension, either alone or in combination with other agents. o Congestive heart failure, left ventricular dysfunction o Diabetes 21. The Prils o Contraindications and Precautions in the Use of ACE inhibitors o Presence of allergy is a clear contraindication.o

28. The sartans o Pharmacodynamics- The mechanism of action of the A-R-B o These agents work by attaching to the Angiotensin II receptors in the vascular smooth muscles and in the adrenal gland. o The action results in VASODILATION because AII action (constriction) is inhibited and BLOCKAGE of aldosterone release 29. The sartans o Clinical Use of the A-R-B o Hypertension, either alone or in combination. o These agents are also used if the patient cannot tolerate the unrelenting cough associated with ACE inhibitors. 30. The sartans o Contraindications and precautions associated with the A-R-B o These agents are contraindicated in the presence of allergy. o It is NOT GIVEN to pregnant mothers because of the associated FETAL DEATH and severe fetal abnormalities. Lactating women should also avoid these drugs because they can affect the neonate. 31. The sartans o Pharmacodynamics: the adverse effects o CNS- headache, dizziness, weakness, syncope and orthostatic Hypotension o GIT- Diarrhea, abdominal pain, nausea, dry mouth and tooth pain o Respiratory- mild cough o Skin- rash, dry skin and alopecia. 32. The sartans o Implementation o Encourage the patient to implement lifestyle changes, including weight loss, smoking cessation, decrease in alcohol and salt in the diet, and increased exercise, to increase the effectiveness of anti-hypertensive therapy. o Administer without regard to meals; give with food to decrease GI distress if needed . 33. The sartans o Implementation o Alert the surgeon and mark the patient's chart prominently if the patient is to undergo surgery to alert medical personnel that the blockage of compensatory angiotensin II could result in hypotension following surgery that needs to be reversed with volume expansion. 34. The sartans o Implementation o Ensure that the patient is not pregnant before beginning therapy and suggest the use of barrier contraceptives while on this drug to avert potential fetal death or abnormalities that have been associated the these drugs.

Find an alternative method of feeding the baby if patient is nursing to prevent the potentially danger- block of the renin-angiotensin system in the neonate. 35. The sartans o Implementation o Monitor the patient carefully in any situation that might lead to a drop in fluid volume (e. g., excessive eating, and vomiting diarrhea, dehydration) to detect treat excessive hypotension that may occur. o Provide comfort measures to help the patient tolerate drug effects (e.g., small, frequent meals; access to bathroom facilities; safety precautions if CNS effects occur environmental control; appropriate skin care needed; analgesics as needed). 36. Calcium channel blockers o These agents prevent the movement of calcium into the cardiac and smooth muscle cells when the cells are stimulated. 37. Calcium channel blockers o This blocking of calcium will interfere with the muscle cell's ability to contract, leading to a loss of smooth muscle tone, vasodilation, and a decrease in peripheral resistance . o These effects will decrease blood pressure, cardiac workload, and myocardial oxygen consumption . 38. Calcium channel blockers o Calcium channel blockers are very effective in the treatment of angina because they decrease the cardiac workload. 39. Calcium channel blockers o Pharmacodynamics: Mechanism of action o Calcium channel blockers inhibit the movement of calcium ions across the membranes of myocardial and arterial muscle cells, altering the action potential and blocking muscle cell contraction. o This effect will depress myocardial contractility, slow cardiac impulse formation in the conductive tissues, and relax and dilate arteries, causing a fall in blood pressure and a decrease in venous return. 40. Calcium channel blockers o The calcium channel blockers that are used in the treatment of hypertension include the following: o The -dipine and others o Diltiazem (Cardizem, Tiamate) o Verapamil o Amlodipine (Norvasc) o Felodipine (Plendil) o Isredipine (DynaCirc) o Nicardipine(Cardene) o Nifedipine (CALCIBLOC, Procardia XL)-prototype! o Nisoldipine (Sular) 41. Calcium channel blockers o CONTRAINDICATION and PRECAUTIONSo

These drugs are contraindicated in the presence of allergy to any of these drugs o With heart block or sick sinus syndrome because these could be exacerbated by the conduction-slowing effects of these drugs o With renal and hepatic dysfunction, which could alter the metabolism and excretion of these drugs; and with pregnancy and lactation because of the potential for adverse effects on the fetus and neonate. 42. Calcium channel blockers o Pharmacodynamics: the ADVERSE EFFECTS o The adverse effects associated with these drugs are related to their effects on cardiac output and on smooth muscle. CNS effects include dizziness , lightheadedness, headache, and fatigue. GI problems can include nausea and hepatic injury related to direct toxic effects hepatic cells. Cardiovascular effects include hypotension, bradycardia, peripheral edema, and heart block . Skin flushing and rash may also occur 43. Calcium channel blockers o Pharmacodynamics: o The main use of calcium channel blockers is the treatment of angina o Also in hypertension o Also in vascular spasm= Raynauds 44. Calcium channel blockers o IMPLEMENTATION o Monitor blood pressure carefully while patient is on therapy because of increased hypotensive episodes o If possible, obtain serial ECG tracing o Provide comfort measures to help patient tolerate drug effects- includes serving small frequent feedings and safety precaution due to hypotension and dizziness 45. Calcium channel blockers o IMPLEMENTATION o Provide health teaching as to drug name, dosage, administration, side effects and warning manifestations to report 46. The Vasodilators o Vasodilators produce relaxation of the vascular smooth muscle, decreasing peripheral resistance and reducing blood pressure. o They cause the reflex tachycardia that occurs when blood pressure drops 47. The Vasodilators o The vasodilators are used to treat severe hypertension 48. Vasodilators o Diazoxide (Hyperstat) o Hydralazine (Apresoline) o Minoxidil (Loniten) o Sodium Nitroprusside (Nitropress)o

Tolazoline (Priscoline) 49. Vasodilators o Pharmacodynamics: mechanism of action of the vasodilators o The vasodilators act directly on vascular smooth muscle to cause muscle relaxation, leading to vasodilation and drop in blood pressure . o They are indicated for the treatment of severe hypertension that has not responded to other therapy. 50. Vasodilators o Contraindications and Precautions o The vasodilators are contraindicated in the presence of known allergy to the drug; with pregnancy and lactation because of the potential for adverse effects on the fetus and neonate; and with any condition that could be exacerbated by a sudden fall in blood pressure, such as cerebral insufficiency. 51. Vasodilators o Pharmacodynamics: the adverse effects of the vasodilators o CNS- dizziness , anxiety, headache o CVS- reflex tachycardia , CHF, chest pain, edema; skin rash, lesions (abnormal hair growth with minoxidil), hypotension o GI upset, nausea, and vomiting 52. Vasodilators o Pharmacodynamics: the adverse effects of the vasodilators o Cyanide toxicity (dyspnea, headache, vomiting, dizziness, ataxia, loss of consciousness, imperceptible pulse, absent reflexes, dilated pupils, pink color, distant heart sounds, shallow breathing) may occur with nitroprusside , which is metabolized to cyanide and which also suppresses iodine uptake and can cause hypothyroidism. 53. Vasodilators o IMPLEMENTATION o Encourage the patient to implement lifestyle changes, including weight loss, smoking cessation, decrease in alcohol and salt in the diet, and increased exercise, to increase the effectiveness of antihypertensive therapy. o Monitor blood pressure closely during administration to evaluate for effectiveness and to ensure quick response if blood pressure falls rapidly or too much . 54. Vasodilators o IMPLEMENTATION o Monitor blood glucose and serum electrolytes to avoid potentially serious adverse effects. o Monitor the patient carefully in any situation that might lead to a drop in fluid volume (e.g., excessive sweating, vomiting, diarrhea, dehydration) to detect and treat excessive hypotension that may occur. 55. Vasodilators o IMPLEMENTATIONo

Provide comfort measures to help the patient tolerate drug effects (e.g., small, frequent meals, access to bathroom facilities safety precaution if CNS effects occur, environmental control, appropriate skin care as needed, analgesic as needed). o Provide thorough patient teaching o Offer support and encouragement to deal with the diagnosis drug regimen. 56. Drugs for the Treatment of Congestive Heart Failure o Vasodilators- Nitrates that act to directly relax vascular muscle tone and cause decrease in blood pressure with pooling of blood in the veins. The preload and afterload will be decreased o ACE inhibitors- are agents that block the conversion of angiotensin I to angiotensin II. The result is blockage of the vasoconstriction and decreased blood volume. The afterload will be decreased. o Diuretics are employed to decrease the blood volume, which decreases the venous return and the blood pressure. The results are decreased preload and decreased afterload. 57. Drugs for the Treatment of Congestive Heart Failure o Beta stimulators will stimulate the beta receptors in the sympathetic nervous system, increasing the myocardial contraction- called positive inotropic effect. o Cardiotonic drugs- these agents affect the INTRACELLULAR calcium levels in the heart muscles leading to increased contractility . The result is increased cardiac output, increased renal blood flow, increased perfusion and increased urine formation. The cardiotonic drugs are: the cardiac glycosides and the phosphodiesterase inhibitors. 58. The cardiac glycosides o These are agents extracted from the foxglove plant. They are available in oral and parenteral preparations. The following are the cardiac glycosides: o Digoxin (Lanoxin) o Digitoxin (Crystodigin) o Ouabain 59. The cardiac glycosides o Pharmacodynamics: the Mechanism of action o They increase the level of CALCIUM inside the cell by inhibiting the Sodium-Potassium pump . o More calcium will accumulate inside the cell during cellular depolarization. 60. The cardiac glycosides o Positive inotropic Effect- the myocardium will contract forcefully Increased cardiac output Increased blood flow to the body organs like the kidney and liver o Negative chronotropic effect- the heart rate is slowed due to decreased rate of cellular repolarization Bradycardia o Decreased conduction velocity through the AV node 61. The cardiac glycosideso

Clinical Use of the cardiac glycosides Treatment of congestive heart failure Treatment of dysrhythmias like atrial flutter, atrial fibrillation and paroxysmal atrial tachycardia 62. The cardiac glycosides o Contraindications and Precautions o Contraindicated in the presence of allergy to any cardiac glycoside. o They are NOT given to patients with ventricular dysrhythmias, heart block or sick sinus syndrome, aortic stenosis, acute MI, electrolyte imbalances ( HYPOKALEMIA, HYPOMAGNESEMIA and HYPERCALCEMIA ) and renal failure (may cause accumulation of drug) 63. The cardiac glycosides o Pharmacodynamics: the Adverse Effects of the Cardiac glycosides o CNS- Headache, weakness , seizures and drowsiness o CVS- arrhythmias o If digitalis toxicity is developing- the nurse must assess the following adverse effects: Anorexia, nausea and vomiting, visual changesYELLOW halo around an object, and palpitations or very slow heart rate 64. The cardiac glycosides o Drug-Drug Interactions o If taken with Verapamil, Amniodarone, quinidine, quinine, erythromycin and tetracyclines- can increase the risk of INCREASED effects of digitalis. o If taken with potassium-losing diuretics like furosemide- can INCREASE the risk of toxicity and arrhythmias. Potassium replacement must be given. o If given with cholestyramine, charcoal and colestipol- can cause impaired absorption of digitalis 65. The cardiac glycosides o Implementation o Administer the initial rapid digitalization and loading dose as ordered intravenously o Monitor the APICAL pulse rate for ONE full minute before administering the drug. Withhold the drug if Less than 60 in adults Less than 90 in infants More than 110 in adults o Retake pulse in one hour, if pulses remain abnormal, refer! 66. The cardiac glycosides o Implementation o Check the spelling of the drug- DIGOXIN is different from DIGITOXIN! o Check the dosage preparation and the level of digitalis in the blood. ( Therapeutic level is 0.5 to 2.0 nanograms/mL ) o Administer intravenous drug VERY slow IV over 5 minutes to avoid arrhythmias. Do NOT administer intramuscularly because it can cause severe pain 67. The cardiac glycosideso o o

This agent is supplied in oral, spray, transdermal and ointment preparations. 77. The Organic nitrates o Pharmacodynamics: the mechanism of action o Nitroglycerin relaxes the smooth muscles in the vascular system by its conversion to nitric oxide, a chemical mediator in the body that relaxes smooth muscles. 78. The Organic nitrates o Administered nitrates o Increased nitrates in the blood o increased formation of nitric oxide o increased cGMP formation o increased dephosphorylation of myosin o Vascular smooth muscle relaxation o vasodilatation 79. The Organic nitrates o Pharmacokinetics- absorption to excretion o It can be given orally, parenterally and topically. o The onset of action of nitroglycerin is more than 1 hour. o Because significant first-pass hepatic effect, Nitroglycerin is given SUBLINGUALY. 80. The Organic nitrates o Pharmacodynamics: Side effects and adverse effects o HEADACHE is the most common effect of nitroglycerin. o CVS- postural Hypotension, facial flushing, tachycardia o TOLERANCE - the tolerance to the actions of nitrates develop rapidly. This can be managed by providing a day of abstinence. 81. The Nitrates o Implementation o Monitor vital signs, especially watchful for hypotensive episodes o Advise patient to remain supine or sit on a chair when taking the nitroglycerin for the first time. Emphasize that he should change his position slowly or rise from bed slowly to avoid orthostatic Hypotension o Offer sips of water before giving sublingual nitroglycerin because dryness may inhibit drug absorption 82. The Nitrates o Implementation o Apply nitroglycerin ointment to the designated mark on paper. o The nurse should remove any excess ointment on the skin from the previous dose. o She should NEVER USE her bare fingers because the drug can be absorbed, utilize gloves or tongue blades instead. 83. The Nitrates o Implementation o Apply nitroglycerin patch to an area with few hairs. Never touch the medication portion.o

The patch and the ointment should NOT be applied near the area for defibrillation because explosion and skin burns may result 84. The Nitrates o IMPLEMENTATION o Emphasize that tolerance to the nitroglycerin can occur. o If the medication cannot relieve the pain, report to the hospital immediately. 85. The Nitrates o IMPLEMENTATION o Provide client health teaching- the sublingual nitroglycerin tablet is USED if chest pain occurs o The dose may be repeated if pain is unrelieved within 5 minutes. o Repeat the medication administration if the pain has not yet subsided . o DO NOT give more than 3 tablets! !! If chest pain persists for more than 15 minutes, hospital consult should be done immediately. 86. The Nitrates o IMPLEMENTATION o Instruct the client to avoid alcohol while taking nitroglycerin to avoid potentiating the hypotensive effect of the medication o If beta blockers and calcium-channel blockers are given, instruct the patients to consult the physician before discontinuing the medication 87. The Nitrates o IMPLEMENTATION o Other components of health teaching for home self-administration: If taking Sublingual Nitroglycerin, the patient should be instructed to place the tablet under the tongue for quick absorption. A burning sensation/biting/stinging sensation may indicate that the tablet is FRESH ! Store the tablet in a dark container , keep it away from heat and direct sunlight to avoid lessening the potency 88. The Nitrates o IMPLEMENTATION o Other components of health teaching for home self-administration: HEADACHES are common in the initial period of nitroglycerin therapy. Advise patient to take PARACETAMOL for relief The nitroglycerin patch is applied once a day, usually in the morning. The sites should be rotated, in the chest, arms and thighs avoiding hairy areas. 89. The Nitrates o IMPLEMENTATION o Other components of health teaching for home self-administration: Position supine with elevated legs to manage Hypotension.o

Nitroglycerin tablet can be taken prophylactically in situations where chest pain is anticipated- Sex, exercise, etc.. If patient is taking beta blockers, instruct how to obtain heart rate in a minute

90. Drugs for Shock o Dopamine o This is a sympathomimetic drug often used to treat Hypotension in shock states that are not caused by Hypovolemia. o This drug is an immediate precursor of nor-epinephrine, occurs naturally in the CNS basal ganglia where it functions as a neurotransmitter. 91. Drugs for Shock o Dopamine o Pharmacodynamics: It can activate the alpha and beta adrenergic receptor depending upon the concentration. It stimulates receptors to cause cardiac stimulation and renal vasodilation . o The dose range is 1-20 micrograms/kg/min 92. Drugs for Shock o Dopamine o Pharmacokinetics: Dopamine is administered IV, excreted in the urine. o At low dose ( 1-2 micrograms ), dopamine DILATES the renal and mesenteric blood vessels producing an increase output (dopaminergic effect) 93. Drugs for Shock o Dopamine o At moderate dose of 2-10 micrograms, dopamine enhance cardiac output by increasing heart rate ( beta 1-adrenergic effect) and elevates blood pressure through peripheral vasoconstriction (alpha adrenergic effect) 94. Drugs for Shock o Dopamine o At higher doses of more than 10 micrograms- vasoconstriction of all vessels will predominate that can lead to diminished tissue perfusion 95. Drugs for Shock o Dopamine o Dopamine is indicated to treat Hypotension, to increase heart rate and to increase urine output (given less than 5 mg/kg/min) o The nurse typically prepares the dopamine drip- dopamine (at a concentration of 400-800 mg) is mixed in 250 mL D5W and administered as drip via an infusion pump for precise dosage administration. o Sodium bicarbonate will inactivate the dopamine 96. Drugs for Shock o Dopamine o Pharmacodynamics: side effects- Tachycardia o hypertension o ectopic beats, angina o dysrhythmias, myocardial ischemia, nausea and vomiting.

97. Drugs for Shock o Dopamine: Nursing consideration Check the IV site hourly for signs of drug infiltration of dopamine, which can cause severe tissue necrosis. Phentolamine should be infiltrated in multiple areas to reduce tissue damage. Drug is effective if Urine output is increased and BP is increased 98. Anti-Arrhythmias o Arrhythmias (sometimes called Dysrhythmias) are conduction dysfunctions caused by abnormalities in impulse generation or impaired transmission of the impulses. o They are simply deviations from the normal rate or pattern of the heartbeat. 99. Anti-Arrhythmias o Four things may happen during arrhythmias: o The heart will beat too FAST (tachycardia, either the atrium or the ventricle) o The heart will beat too slow (bradycardia) o The heart will respond to other impulses generated by the cardiac cells (other than the SA node) o The heat will respond to impulses traveling along extra pathways 100. Anti-Arrhythmias o Anti-arrhythmic agents are given to modify impulse generation and conduction. o The desired action of these antidysrhythmics is to restore the cardiac rhythm to normal. o They affect the action potential of the cardiac cells, altering their automaticity, conductivity, or BOTH 101. Anti-Arrhythmias o Because the anti-arrhythmic drugs affect the conduction system, they also can produce ARRHYTHMIAS! o They are also Pro-Arrhythmics! 102. Anti-Arrhythmias o The classes of anti-arrhythmic agents: o Class 1 agents - are fast SODIUM channel blockers that affects the depolarization phase. o Class 2 agents- are BETA blockers that affect the depolarization. o Class 3 agents- are POTASSIUM channel blockers that diminish the outward potassium current during repolarization of cardiac cells. o Class 4 agents- are calcium channel blockers that decrease the calcium influx into the specialized cardiac muscle cells causing slowed conduction 103. Anti-Arrhythmias o The classes of anti-arrhythmic agents: o Class 1 agents Class 1 A- Quinidine, Procainamide, Disopyramide, Moricizine Class 1 B- Lidocaine, Mexiletine, Tocainide